Management of Obstetric Analgesia in the Developing Countries during the Coronavirus Disease Pandemic: A Narrative Review.

Coronavirus disease (COVID), also known as COVID-19, has brought the immense challenges for the health-care system globally. All the branches of medicine are equally involved in managing these patients. During this pandemic, care of obstetric patients in terms of obstetric analgesia becomes crucial. Hence, the purpose of this review was to draft a basic model of strategies related to the provision of safe obstetric analgesia during this coronavirus pandemic, which will assist the health-care providers across the developing countries to formulate their own protocols depending upon the resource availability. All research articles related to obstetric analgesia during the COVID-19 pandemic from January 2020 to December 01, 2020 available on PubMed, Cochrane, Google scholar, and Embase are included in this study. The keywords used for data search were "obstetric analgesia during COVID-19," "coronavirus pandemic," "Labor pain," "obstetric pain management guidelines," and "regional anesthesia during COVID-19." Eventually, our review yielded the most recentmodel for the provision of safe and effective obstetric analgesia practices during the COVID-19 pandemic across the developing countries. Copyright:

INTRODUCTION

In developing countries, the pain management of parturients infected or suspected with coronavirus disease 2019 (COVID-19) requires a wide spectrum of clinical considerations, ranging from the provision of peripartum analgesia to the parturients to the prevention of health-care workers from getting infected during the process of hospitalization and delivery. The aim of this article is to assist developing countries in the construction of indigenous analgesic recommendations that is safe and effective for the parturients and health-care professionals and that can be easily implemented by the anesthesiologists across the developing nations during this COVID-19 pandemic. Considering these recommendations as a basic model [Figure 1], additionally, health caregivers in a country can formulate their own guidelines based on the availability of recent data, workforce, and available resources.

Figure 1

Suggested model for developing obstetric analgesia guideline during COVID-19 pandemic

MATERIALS AND METHODS

With numerous articles published in relation to the analgesic management of parturients during the COVID-19 pandemic, a review keeping in mind the status of developing country was due. Our main focus was to search for the literature corresponding to guideline formulation in developing countries. In this review, all research articles related to obstetric analgesia during the COVID-19 pandemic, which were published from January 2020 to October 1, 2020, were analyzed and discussed. All the available guidelines for managing obstetric pain services and safe practice of regional anesthesia (RA) during this pandemic were also analyzed. Literature for this research was identified by searching the online databases such as PubMed, Google scholar, and Embase. The keywords used for the data search were “obstetric analgesia during COVID-19,” “coronavirus pandemic,” “labor pain,” “obstetric pain management guidelines” and “regional anesthesia during COVID-19.”

Guidelines from the American Society of RA (ASRA), Society for Maternal-Fetal Medicine, Society for Obstetric and Anesthesia and Perinatology, Federation of Obstetric and Gynecological Societies of India (FOGSI), and International Anesthetic Research Society were extensively studied and analyzed. Furthermore, the World Health Organization (WHO) database of publications on novel coronavirus was screened for the potentially relevant publications.

CHALLENGES IN OBSTETRIC ANALGESIA

High-risk cases and asymptomatic cases

Most of the symptoms of advance labor like dyspnea, flu-like symptoms, headache, fever, and other nonspecific symptoms are also seen in high-risk cases of COVID-19. At the same time, most of the parturients are asymptomatic until the actual labor sets in and providing obstetric analgesia without adequate protection may lead to accidental exposure of health-care workers to this deadly virus. Hence, the identification of both varieties of these cases possesses a significant challenge to the health-care system of developing countries.

Multidisciplinary team

In developing countries, especially in the government setups, it is very difficult to prepare a dedicated COVID-19 obstetric analgesia team which consists of trained obstetric anesthesiologists, skilled obstetricians, intensivists, pediatricians, and skilled nursing staff as there is the limitation of workforce in terms of health-care workers.[1]

Personal protective equipment's and other logistics

There is a gross lacking of protective clothing and equipment such as personal protective equipment (PPE), N-95 or filtering face piece (FFP) face masks, protective glasses, in developing countries. Deficiency in negative pressure labor rooms, COVID-19 dedicated units, equipment-like patient controlled analgesia pumps, medicines such as opioids or alpha 2 agonists (α2), and monitoring systems dedicated to COVID-19 patient, additionally complicates the situation in developing countries.

SYMPTOMS AND SIGNS OF CORONAVIRUS DISEASE IN PREGNANCY

Across the globe, the reported clinical features in pregnant women with COVID-19 infection have been similar to those reported among nonpregnant patients.[234] The common findings that have been reported include fever, fatigue, and dry cough, whereas dyspnea, general flu-like symptoms including muscular pain, headache, sore throat, diarrhea, nausea, vomiting, and sudden loss of the sense of smell and taste have been also reported in few patients.[56] In pregnancy, most of these symptoms can be nonspecific and may be related to the symptoms of pregnancy and labor.[3] In addition, a vast majority of patients can be asymptomatic until the actual labor sets in. Hence, every parturient must be evaluated carefully in terms of history and physical examination before any analgesic intervention to avoid the further propagation of disease to caregivers as well as family members.

SUGGESTED PRACTICE RECOMMENDATIONS FOR DEVELOPING COUNTRIES

Investigations including coronavirus disease-19 screening

Prior to any analgesic intervention, few investigations must be performed. This has two components:

Screening for coronavirus disease-19 infection

COVID-19 screening must be done at the time of admission, if a parturient is having symptoms suggestive of COVID, having positive travel history or had contact with infected patients as most of the parturient may be asymptomatic at the time of admission. Screening tests performed depend upon the institutional availability of particular kit/assay. The aim of screening test is to prevent mother to fetus transmission and to prevent its further spread to caregivers and relatives.

Routine tests

This includes complete blood count including platelet count and estimation of coagulation profile as the range of coagulation abnormalities may co-exist in COVID-19 patients[7] and overlooking it may yield devastating outcomes such as subarachnoid hemorrhage while performing a neuraxial blockade. Previous studies from China also suggested that thrombocytopenia may be associated with COVID-19 infection.[8] From previous studies, it may be considered safe to perform central neuraxial interventions and all other RA procedures at platelet counts of 70,000 × 106 L − 1 or above.[9] The rest other investigations may be performed depending upon the patient clinical profile and institutional protocol keeping adequate safety measures.

PREPARATION INCLUDING LOGISTICS

Team

It will consist of experienced anesthesiologists, obstetricians, and other clinicians and support staff, involved in the implementation of protocols related to the analgesic management of COVID-19 patients. All the planning including emergency scenarios must be discussed with each member of the team before performing any pain-relieving intervention.

Labor and delivery unit

Apart from a skilled team, support structure in form of a well-equipped delivery unit having adequate monitoring system (vital monitoring including continuous pulse oximetry), alarm system along with telemedicine services, is mandatory for the proper implementation of peripartum analgesia in COVID-19 patients.

Safety measures

It includes the wearing of PPE, which consists of gloves, protective gowns, fluid-resistant aprons, visors, and N-95 or FFP facemasks as per the availability or institutional protocol for the prevention of further spread of infection. There should be designated area for proper hand hygiene, donning, and doffing of PPE's.

Logistics

It includes the availability of adequate amount of functioning equipment (ultrasonography machine, nerve stimulators, various needles, epidural kits with filter, patient-controlled analgesic infusion pumps, monitoring devices, and resuscitation systems) and medicines (local anesthetics, short-acting opioids, intravenous anesthetic agents, inhalational agents, and resuscitation drugs).

Training

All those personnel, who are involved in the management of obstetric patients during this COVID era must be trained in terms of donning and doffing of PPE's, delivery of health-care services, instrumentation, monitoring, and disposal of waste materials must be trained in a proper way by the experts in that field as recommended by the WHO or indigenous guidelines before their services in COVID ward or operation theaters.

Analgesic concerns

It can be further divided into three parts, i.e., during labor, analgesia for cesarean delivery, and postpartum analgesia including postdural puncture headache management.

DURING LABOR

Epidural analgesia

Till now, published literature to support any particular practice recommendations for labor analgesia is limited, but based on recent studies,[1011] in various developing countries along with the Indian Council of Medical Research and FOGSI recommendations (The FOGSI),[12] epidural analgesia can be considered a safe alternative for managing labor pain during COVID-19 pandemic in the developing world. Early placement of epidural analgesia is recommended, as it reduces the excessive respiratory exacerbations secondary to labor pain.[10] The advantage of epidural analgesia can be explained in terms of avoiding any exacerbation of respiratory condition with intubation and mechanical ventilation along with the reduction of aerosol generation during airway manipulation if general anesthesia is provided, thereby preventing the further spread of disease.[10]

The placement of epidural analgesia is considered as low-risk procedure as it is associated with minimal aerosol generation.[10] Since uncomplicated pregnancy is associated with an increase in platelet aggregation and decrease in circulating platelets, thrombocytopenia should be anticipated in term pregnant patients with COVID-19, irrespective of infection severity.[13] Therefore, it is recommended to have platelet count check before epidural or spinal anesthesia placement.

As such, for neuraxial placement, a hat, eye protection, a surgical mask, sterile fluid-resistant long-sleeved gown, and sterile gloves should be worn.[14] The patient should be provided with a N-95 or FFP or surgical mask depending upon the availability at all times to avoid the further spread of virus, and the number of personnel present during the placement of neuraxial labor analgesia should be minimized, but with assistance readily available.[10] Many authors in the developing countries, including India, have given importance for the early implementation of epidural analgesia in COVID-19 parturients.[15]

Following strategy can be implemented as the per International Anesthesia Research Society[10] during epidural analgesia, placement for minimizing the contamination of devices and reduction of resources such as PPE's [Table 1].[10]

Table 1

Strategy for minimizing device contamination and resource wastage as per the International Anesthetic Research Society

Limit in-person encounters for preanesthesia evaluations by utilization of videocalling services like WhatsApp or others (including for antenatal consultations)

Encounters should be limited upon admission to the labor floor

Limit the use of devices such as pens or boards for written consents by the use of electronically documented witnessed verbal consents (if possible)

Avoid bringing into the patients’ room the epidural cart or tray - the required equipment (epidural kit) and drugs should be prepared and brought into the room in a bag prior to the procedure

The most experienced anesthesiologist should perform the procedure to ensure adequate placement of epidural catheter and reduce the risk of accidental dural puncture

The dosing of neuraxial medications can be increased for labor analgesia (e.g., increasing the bupivacaine concentration from 0.0625% to 0.1%) or setting of the programmed epidural intermittent bolus can be changed (e.g., increasing the volume from 5 ml to 8 ml or decreasing the interval from every 45 min to 30 min) or adding neuraxial adjuvants (e.g., epidural clonidine) for minimizing breakthrough pain requiring epidural top-up

Round on parturients should be done with video or phone calls for hourly assessments of general status and effects of neuraxial analgesia

Appropriate cleaning of all equipment in the room including the epidural pump and the on demand-button must be ensured

Prolonged patient-controlled epidural analgesia services should be suspended (if possible)

Nitrous oxide (Entonox)

Current status for labor analgesia suggests that “there is insufficient information about the cleaning, filtering, and potential aerosolization of nitrous oxide in the setting of COVID-19,” and additionally, the practice of high flow oxygen for fetal distress does not improve fetal outcomes.[16] Therefore, even in developing countries in anesthesiologists should not recommend the use of nitrous oxide for the management of labor pain.

Opioid patient controlled analgesia

In parturients with COVID-19 infection, opioid patient controlled analgesia (PCA) should be used with extreme precaution in labor to avoid respiratory depression, especially in parturients having respiratory complaints. If needed, short-acting opioids such as remifentanil can be used for a brief duration with adequate oxygen saturation (SPO2) monitoring, and it should be omitted in parturients with SPO2 <95% to avoid further desaturation.[10]

Analgesia for cesarean delivery

If a parturient smust be followed with utmost importancei placed for cesarean delivery, either planned or emergency, analgesic concerns can be taken care by epidural extension of labor analgesia or spinal anesthesia or placement of combined spinal-epidural anesthesia. These methods are preferred to avoid the risks of aerosolization associated with tracheal intubation and extubation.[10] The most skilled anesthesiologist should perform these procedures under sterile conditions with adequate monitoring as recommended by the American Society of Anesthesiologists. If needed, COVID-19 dedicated ultrasonography machine can be used to assist the neuraxial blockade. Longer-acting medications such as bupivacaine and ropivacaine are recommended agents for providing the prolonged duration of analgesia. Safety considerations including wearing of PPE's should be taken every time to ensure the safety of health-care workers.

Regional anesthesia including truncal blocks

As per the European Society of RA (ESRA) and ASRA guidelines for regional anesthesia, neuraxial anesthesia, and peripheral nerve blocks in COVID-19 patients,[17] the use of RA is not contraindicated, and ultrasonography (USG) guidance is recommended for the peripheral nerve blocks. Prior to block placement, risk-benefit ratio should be analyzed for perineural adjuvants and continuous perineural catheters. The benefit of perineural adjuvants must be balanced against the risks of possible immunosuppression (dexamethasone), sedation, bradycardia and hypotension (clonidine and dexmedetomidine), drug errors, and drug contamination.[16] In order to avoid disease propagation, drugs should be prepared outside the procedure room and packed in a plastic bag or container and block should be placed using safe practices. Currently, no dose adjustment for RA is recommended. All the truncal blocks which do not require repositioning of the patient like transverses abdominis plane block and rectus sheath block can be placed in parturients following surgery.[17] Therefore, the use of RA can be recommended as a pain-relieving procedure following surgery for parturients undergoing cesarean delivery. In addition, developing countries can formulate their own guidelines or can follow society recommendations by ESRA and World Federation of Societies of Anesthesiologists.

Postpartum analgesia

It can be provided through two ways either using R. A. techniques utilizing continuous catheters or through oral analgesic medications. The use of PCA pumps utilizing opioids for prolonged duration should be avoided in view of worsening of respiratory symptoms. Regarding nonsteroidal anti-inflammatory drugs (NSAIDS), it was postulated that it may worsen the clinical symptoms of COVID-19 patients; however, this statement remains controversial and evidence is still lacking. Therefore, in current situation, NSAIDs can be recommended in those parturients whose pain is unresponsive to paracetamol as a safe alternative to opioids.[1016]

Analgesia for postdural puncture headache

Till now, no case of postdural puncture headache (PDPH) has been reported in view of COVID-19 pandemic. Therefore, till now, no guidelines have been reconstructed. Hence, we recommend the conservative management as an initial therapeutic approach. Usual contraindications to the performance of an epidural blood patch (e.g., fever, thrombocytopenia, or other coagulation issues) should also apply in a COVID-19 patient.[10] Interventions such as nasal sphenopalatine ganglion (SPG) block should be avoided as it is likely to aggravate the aerosol production, thereby increasing the risk of disease propagation.

CONCLUSIONS

The key point to our article regarding analgesic concerns in obstetric patients in developing countries during COVID-19 pandemic is to promote the early implementation of epidural analgesia for managing labor pain as it reduces the excessive respiratory exacerbations secondary to labor pain. RA including truncal blocks utilizing USG can be performed safely in COVID-19 parturients and blocks for managing PDPH like SPG block should be avoided in view of aerosolization of the ambient atmosphere. At all times, a protocol for safeguarding health-care personnel's like wearing of PPE's and respirators, must be followed with utmost importance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.